Nicardipine
Cardene
Dihydropyridine calcium channel blocker (vascular-selective)
Selective L-type voltage-gated calcium channel blocker, dihydropyridine class (vascular >> cardiac selectivity). Vascular smooth muscle relaxation → arterial vasodilation → afterload reduction. Minimal direct cardiac inotropic or chronotropic effect at clinical doses (vs verapamil/diltiazem which are non-selective).
Indications
- •Acute hypertension management — perioperative HTN, hypertensive emergency, post-CV surgery
- •Acute aortic dissection (after beta-blocker)
- •Pulmonary hypertension acute management (some evidence)
- •Cerebral vasospasm prophylaxis (subarachnoid hemorrhage — nimodipine PO preferred for cerebral)
Dosing
| Context | Adult | Pediatric |
|---|---|---|
| Acute HTN bolus | 0.5-1 mg IV q5min titrated; or 5 mg IV bolus | — |
| Continuous infusion | 5-15 mg/h IV titrated to target BP (typical 10-15 mg/h) | — |
| Aortic dissection (after beta-blocker) | 5-15 mg/h IV titrated to SBP <120 | — |
Pharmacokinetics
Onset 5-15 min IV bolus; 30-60 min infusion to peak. Duration 30-60 min after stopping infusion (longer than nitroglycerin). Hepatic metabolism via CYP3A4 (drug interactions). Half-life 2-4 h with linear kinetics. Active metabolite minimal.
Hemodynamic effects
↓SVR → ↓BP via afterload reduction. Reflex tachycardia (modest, usually 5-10 bpm). Minimal effect on contractility, conduction, or HR direct effects. Does NOT cause aortic dissection extension (in contrast to pure vasodilators that drop SVR rapidly without HR control).
Side effects
- !Hypotension (additive with anesthetics)
- !Reflex tachycardia
- !Headache, flushing (vasodilation)
- !Phlebitis at infusion site (peripheral OK; central preferred for sustained infusion)
- !Nausea/vomiting
Contraindications
- ×Severe aortic stenosis (afterload reduction increases gradient + decreases CPP)
- ×Acute MI with hypotension
- ×Hypersensitivity
Clinical pearls
- ★PREFERRED FIRST-LINE for intraop HTN in non-cardiac surgery — easier to titrate than nitroprusside (no cyanide), no rebound tachycardia of nitroglycerin, longer duration than esmolol.
- ★Combine with esmolol or labetalol for tachycardia + HTN (ESMOLOL FIRST in dissection — esmolol prevents reflex tachy).
- ★INFUSION PUMP titration: typical adult 5 mg/h start, increase by 2.5 mg/h q5-15 min until target. Once at target, titrate downward as anesthetic stabilizes.
- ★Cerebral effects: causes mild cerebral vasodilation (may raise ICP transiently); use cautiously in elevated ICP — but blood pressure control + cerebral perfusion preservation usually outweighs.
- ★Switch to oral antihypertensive (amlodipine, labetalol PO) before stopping infusion — some patients have rebound HTN.